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<br />1 .\ 1 APPLICATION FOR WELL OR PUMP PERMIT <br />(Complete in Triplicate) , . <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />FOR, OFFIG•E USE: <br />PERMIT NO, / I <br />Date Issued: / fq• <br />APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br />THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br />NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br />JOB ADDRESS/LOCATION:k e)` <br /> ‘7-""s vN--LQ ‘'eL41 E <br />CENSUS <br /> pT IRAforiCTE: ‘,5 - 1 -7 S' <br />OWNER'S NAME: INAQ, <br />ADDRESS: t1(M. v"1: bz Lvi (A CITY: CONTRACTOR'S NAME: ALAlp,__114._ LICENSE # Op -1 -111 PHONE: 24GD6 -'r.;a 2- 5- <br />INTENDED USE: INDIVIDUAL DOMESTIC WATER WILL PUBLIC WATER WELL // TEST WELL /1 f RRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL 1/ <br />CATHODIC PROTECTION WELL // GEOPHYSICAL WELL Li OTHER / / — <br />,IEW WELL: DISTANCE TO NEA5L SEPTIC TANK SEWER LI PIT NRRIVY SEWAGE DISPOSAL FIELD CESSPOOL GE PIT OTHER <br />tEPAIRS: TYPE OF REPAIRS: -kLa <br />ta1k- Phr U ke+ <br /> <br />BANDONMENT/DESTRUCT ON: MET OD TO BE USED: , <br />LOT PLAN: SHOW ON REVERSE SIDE <br />aER Y CERTIFY THAT HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br />:O0 ANCE WITH THE P VISIONS OF HE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br />)UNT OF SAN .JOAUI< AND THE R REGULATIONS OF THE SAN JOA UIN LOC HEAby DISTRICT. <br /> CONTRACTOR: <br />LASE <br /> <br />FOR DEPARTMENT USE ONLY <br /> <br />TIICATION ACCEPTED BY: <br />OITIONAL COMMENTS: <br /> <br />DATE: /I— <br /> <br />1 1 <br />LGNED: <br />PHASE II II PHASE III/FINAL <br />/ <br />SPECTION BY: lt-J, DATE - 3- 7.2_ INSPECTION BY6rd-//40( DATE 2-2 H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M STRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR